Using interactive learning activities to predict learning outcomes in medical education: a mixed-methods study

BACKGROUND: Active learning methods are increasingly used in medical education to enhance engagement and retention; however, limited evidence links performance on embedded formative assessments to summative examination outcomes in large-group pre-clinical settings. Interactive Learning Activities (ILAs) incorporating low-stakes quizzes were implemented in a first-year Cardiopulmonary-Renal (CPR) systems course. This study aimed to determine whether ILA quiz performance was associated with summative examination outcomes and to explore student perceptions across academic performance tiers. METHODS: A sequential explanatory mixed-methods study was conducted across two academic years (2022: n = 156; 2023: n = 160). ILAs included pre- and post-session quizzes, contributing 5% to the final course grade. Linear regression and correlation analyses examined associations between mean ILA quiz scores and summative examination performance. Students were stratified into tertiles of final course grade for survey comparisons. An anonymous post-course survey collected Likert-scale and open-ended responses. Quantitative survey data were analyzed using chi-square tests, and qualitative responses were analyzed using Braun and Clarke's thematic analysis framework. RESULTS: The ILA quiz scores demonstrated consistent moderate-to-strong positive correlations with overall examination performance in both cohorts (2022: R = 0.641; 2023: R = 0.672). Combined analysis confirmed a stable association (R = 0.632). Association was evident early in the semester, by the 6th ILA. Survey responses (25.6% response rate) indicated generally positive perceptions of ILAs. Lower-performing students reported comparatively high perceived learning benefits, whereas middle-tier students more frequently expressed concerns about quiz-related stress and workload (p < 0.05 for selected items). Qualitative themes highlighted engagement, retrieval practice, and timely feedback as strengths, with graded timing and stress as primary concerns. CONCLUSION: Performance on low-stakes ILA quizzes was consistently associated with summative examination outcomes in a large-group pre-clinical course. Embedded formative assessments may serve both instructional and early indicator functions, supporting early identification of students who may benefit from additional academic support.